All Entries Tagged With: "IPPS"
CMS issues IPPS proposed rule for FY 2013
CMS released the 2013 IPPS proposed rule Tuesday night.
Inpatient acute care hospitals could see a 2.3% increase in payment rates under the fiscal year (FY) 2013 Inpatient Prospective Payment System (IPPS) proposed rule, released April 24. The 2.3% is a net update after inflation, due to improvements in productivity, a statutory adjustment factor, and adjustments for hospital documentation and coding changes.
In addition, the IPPS proposed rule contains provisions to strengthen the Hospital Inpatient Quality Reporting (IQR) Program and proposes new policies and measures for the Hospital Value-Based Purchasing (VBP) Program.
“If the goal is to reward excellence, hospitals have to ensure that their coders are up to speed with appropriate identification of complications and with [present on admission] POA indicators as well as the over-documentation issues that could lead to financial penalties,” says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.
CMS also proposes a methodology to calculate the readmissions adjustment factor for inpatient hospitals that could result in a 0.3% decrease in overall payments to hospitals.
Coding changes
As expected, there were few changes to the ICD-9-CM code set. CMS previously indicated that it would limit such changes to allow providers time to prepare for ICD-10 implementation previously slated for October of 2013 but now potentially delayed until October of 2014.
“Since we are proposing to use ICD-9-CM until October 1, 2014, it potentially adds another year of limited updates,” says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro, Inc, in Danvers, Mass.
For FY 2013, CMS proposes to reassign cases with a principal diagnosis code 487.0 (influenza with pneumonia) and a one of a list of pneumonia codes listed as a secondary diagnosis codes from MS-DRGs 193, 194, and 195 to MS-DRGs 177, 178, and 179. CMS proposes to make three additional codes complications and comorbities (CCs) and change one major CC (MCC) to a CC for FY 2013. It does not plan to add any MCCs or delete any CCs.
CMS proposes adding these diagnoses to the CC list:
- 263.0, Malnutrition of moderate degree
- 263.1, Malnutrition of mild degree
- 440.4, Chronic total occlusion of artery of the extremities
It also is proposing to change the severity level of diagnosis code 584.8 (acute kidney failure with other specified pathological lesion in kidney) from an MCC to a CC.
“While I support many of their CC/MCC changes, such as making mild and moderate malnutrition a CC, I am saddened that CMS still refuses to make heart failure not otherwise specified a CC,” says James S. Kennedy, M.D., C.C.S., C.D.I.P., managing director at FTI Consulting in Brentwood, Tenn.
IQR proposed changes
The IQR program currently includes 72 quality measures. CMS has proposed reducing that number to 59 for the FY 2015 payment determination, and 60 for the FY 2016 payment determination.
Participation in the IQR program is optional, although those who choose not to participate receive a 2% reduction in the annual payment update. CMS proposes adding perinatal care and readmissions, including overall readmissions and readmissions relating to hip and knee replacement procedures to the IQR quality measures for FY 2013. In addition, CMS would also measure how well hospitals use a surgery checklist designed to reduce errors.
VBP proposed changes
Beginning in FY 2013 and continuing annually, CMS will adjust hospital payments based on how hospitals perform or improve their performance on a set of quality measures.
For the FY 2014 VBP Program, the proposed rule includes a new outcome measure that rewards hospitals for avoiding central line-associated bloodstream infections that can develop during inpatient hospital stays.
For the FY 2015 VBP Program, CMS proposes grouping and scoring measures in four domains—clinical process of care, patient experience of care, outcome, and efficiency. CMS also proposes adding a total of four new measures to the list.
Readmissions reduction program methodology
In the FY 2012 IPPS final rule, CMS began implementation of the Readmissions Reduction Program for three conditions:
- acute myocardial infarction (i.e., heart attack)
- heart failure
- pneumonia
CMS also finalized its definition of readmission as:
“occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period [30 days] from the time of discharge from the index hospitalization.”
CMS also addresses these areas related to the program:
- Adjustment factor (both the ratio and floor adjustment factor)
- Aggregate payments for excess readmissions and aggregate payments for all discharges
- Applicable hospital
- Limitations on review
- Reporting of hospital-specific information, including the process for hospitals to review and submit corrections
Additions to the HAC list
CMS proposes adding two conditions to the list of hospital acquired conditions (HACs) for 2013:
- surgical site infection following cardiac implantable electronic device (CIED)
- iatrogenic pneumothorax with venous catheterization
Inpatient facilities do not receive higher MS-DRG payments for patients with complications or major complications caused by the conditions on the HAC list. CMS plan to update the existing vascular catheter-associated infection HAC category by adding the following two codes:
- 999.32 (bloodstream infection due to central catheter)
- 999.33 (local infection due to central venous catheter)
CMS proposed adding pneumothorax associated with transbronchial biopsy several years ago, but it was not finalized, McCall says. This condition does seem to meet HAC the criteria of occurring commonly and can cause a significant increase in resource consumption in order to treat this condition, she says. It is also labeled as a complication and comorbidity. However, HACs must also be reasonably preventable, according to evidence-based research, and this has also kept other conditions, such as ventilator-associated pneumonia, off the list in the past.
The addition of the surgical site infections from CIEDs seems to follow along with the inclusion of other site infections already on the HAC list, especially given an increased focus on ensuring sterile environments to avoid contamination of a primary infection at the time of placement of such devices, McCall says.
Coding and documentation adjustment
CMS expects the FY 2013 proposed documentation and coding adjustment (DCA) to net an aggregate increase of 0.2%. The DCA was originally established at the time CMS implemented MS-DRGs. It was thought that due to the increased need for specificity, facilities would focus attention on improvements to documentation. The last two years, the DCA has resulted in a payment offset of -2.0% and -2.9%.
“In good news, the documentation and coding adjustment actually works in the provider’s favor this year, increasing reimbursement by 0.2%,” Kennedy says. “That’s a substantial increase from the previous years.”
Comment on the proposed rule
CMS will accept comments on the proposed rule until June 25 and will respond to all comments in a final rule to be issued by August 1, 2012. Facilities can download a display copy of the proposed rule here.
The proposed rule will appear in the May 11, 2012 Federal Register.
Editor’s Note: This article first appeared as a “Breaking News Alert” and was published on HCPro.com.
Q&A: Where to find CC/MCC designations
You've got questions? Lynne's got answers.
Q: How do you know when a condition has a complication comorbidity (CC) or major CC (MCC) designation?
A: Initially, you’ll have to refer to the current fiscal year CC and MCC lists which are published as part of the Inpatient Prospective Payment System Final Rule by CMS, typically the first week in August. CMS lists CC/MCCs by codes, numerically, so every year I take CMS’ lists and reorganize them alphabetically, by condition, so non-coders will have an easier time finding what they need.
The new, FY 2012, CC and MCC lists (alphabetical) have been uploaded to the ACDIS web site in the Forms & Tools Library under “Policies, Procedures, Regulations, and Job Descriptions.” You must be an ACDIS member to access this link. I have also uploaded a document showing the new CC and MCC diagnoses as well as the deleted/changed CC/MCC conditions in the same location.
Over time, you may consider developing your own “short list” of CC and MCC conditions to use for reference. After reviewing charts for several months, you will probably memorize the conditions you see most frequently, or if you are unit-based, consider developing lists for the types of patients you see: cardiac, respiratory, neuro, ortho, etc.
CMS releases FY 2012 IPPS final rule
CMS released its final rule for the FY 2012 Inpatient Prospective Payment System integral to inpatient Medicare reimbursement at short-term and long-term acute care hospitals as announced in an August 1 press release.
In a major surprise, CMS finalized a documentation and coding adjustment (DCA) of -2.0% instead of the proposed -3.15% for fiscal year (FY) 2012, according to the 2012 inpatient prospective payment system (IPPS) final rule released August 1.
CMS originally proposed a year-over-year reduction of 0.5% in payments to acute care hospitals under the FY 2012 IPPS, including a DCA of -3.15%. However, CMS finalized a cut of 2.0%, a decrease from 2.9% in FY 2011, which translates to $1.13 billion more in hospital payments in FY 2012 than they had received in the previous year. “We’re very pleased to see that CMS has scaled back their proposed coding cuts,” says Joanna Kim, senior associate director for policy for the American Hospital Association (AHA) in Washington, DC. “We are quite disappointed that CMS did not change their methodology of analyzing documentation and coding, but are glad they recognized that the proposed 3.15% cut would be very difficult for hospitals to absorb all in one year.”
Kim suggests that hospitals look closely at the new payment rates and make sure they can budget appropriately.
James S. Kennedy, MD, CCS, managing director for FTI Healthcare in Atlanta, agrees that the temporary reprieve is a positive for hospitals. “The DCA is what it is. At least for next year, it’s good that we got a break,” he says. “But CMS will maintain its current methodology of calculating it and will continue to assess it to hospitals until they have recouped what they believe they have overpaid.”
“We recognize the concerns regarding possible financial disruption that may be caused by the proposed documentation and coding improvement payment adjustment,” CMS states in the rule. “We note, however, that these payment adjustments are necessary to correct past overpayments due solely to documentation and coding improvements. We have already delayed implementation of the required prospective adjustment amount, and we proposed only a portion of the remaining required adjustment to allow hospitals time to adjust to future payment differences and to moderate the effect of this adjustment in any given year.
Editor’s Note: This article was initially send to ACDIS members on Tuesday, Aug. 2. Read the complete analysis online at www.hcpro.com
House and Senate urge CMS to reconsider IPPS coding offset
With all the wrangling over the Federal debt and other items at least there is something the House and Senate do agree on—urging CMS to reconsider its coding offset when it publishes its inpatient prospective payment system final rule for 2012 expected to be released any day.
If CMS does include the coding offset “the policy would cut hospital payments by 6.05%, or $6.3 billion, and would create substantial volatility in inpatient PPS rates for the next two years,” according to an article in AHA News.
The proposed rule this year contained a proposed payment reduction of nearly a half a billion dollars compared to payments in 2011, according to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc., in Marblehead, MA. “This reflects a controversial documentation and coding adjustment of -3.15%. This is greater than expected, although CMS indicates they are required to recoup 3.9% and will recoup the remaining .75 in the future to avoid too great an impact on hospitals in 2012,” Hoy wrote on the MedicareMentor Blog when the proposed rule was released earlier this year.
CMS methodology to calculate IPPS coding adjustment “flawed,” reports AHANewsNow
AHANewsNow, the highly recommended daily publication of the American Hospital Association, published a very interesting news item yesterday regarding the documentation and coding adjustment (DCA).
The report states that CMS’ methodology for calculating the DCA is flawed as it ”fails to separate documentation and coding effects from true case mix change.” This is according to an assessment prepared by Joseph Newhouse, a healthcare payment expert who serves on the Congressional Budget Office Board of Health Advisors and co-chairs the 2010 Technical Review Panel on the Medicare Trustee Report. The AHA sent the assessment in a letter to CMS yesterday.
The AHA, the Federation of American Hospitals, and the Association of American Medical Colleges urges CMS in the letter to use a different methodology that “adequately separates true case mix change from documentation and coding, or decrease its estimate of documentation and coding change to account for real case mix change.”
IPPS Final Rule includes DCA adjustment, reduction of AKI to CC
On July 30, CMS issued the inpatient prospective payment system (IPPS) final rule to update policies and rates for fiscal year (FY) 2011, which maintains long-standing CMS policy and implements some provisions of the Patient Protection and Affordable Care Act (PPACA).
CMS updated acute care hospital rates by 2.35%. This update reflects a market basket increase of 2.6% for inflation, which is a slight increase over the FY 2010 inflation rate. The final rule reduces the 2.6% inflation update by 0.25%, as required by PPACA.
Despite strong opposition from the hospital community, CMS also finalized its proposed documentation and coding adjustment (DCA) of -2.9% to offset overpayments that resulted from documentation and coding practices under the new Medicare Severity DRG (MS-DRG) system that in their opinion, did not reflect actual increases in patient severity. CMS states in the final rule:
Under legislation passed in 2007, CMS is required to recoup the entire amount of FY 2008 and 2009 excess spending due to changes in hospital coding practices no later than FY 2012. CMS has determined that a -5.8% adjustment is necessary to recoup these overpayments. The -2.9% adjustment for FY 2011 is one-half of this amount.
- Clarification of CMS’ three-day payment
- Division of MS-DRG 9 (Bone marrow transplant) into two new MS-DRGs—14 (Allogenic bone marrow transplant), with a relative weight of 11.5947 and MS-DRG 15 (Autologous bone marrow transplant), with a relative weight of 5.9504.
- Inclusion of ICD-9-CM code 251.3 (postsurgical hypoinsulinemia) as an acceptable principal diagnosis for MS-DRG 8 (Simultaneous kidney/pancreas transplant) and MS-DRG 10 (Pancreas transplant
- Reductions in the relative weight of five MS-DRGs—622 (Skin grafts and wound debridement for endocrine, nutritional and metabolic disorders with MCC), -19.2%, 855 (Infectious and parasitic diseases with operative room procedure without CC/MCC), -19.0% , 10 (Pancreas transplant), -11.5%, 420 (Hepatobiliary diagnostic procedures with MCC), -11.5%, 624 (Skin grafts and wound debridement for endocrine, nutritional and metabolic disorders without CC/MCC), -10.5%,
- Increases in the relative weight of five MS-DRGs—770 (Abortion with dilation and curettage, aspiration curettage, or hysterotomy), 30.8%, 585 (Breast biopsy, local excision and other breast procedures without CC/MCC), 21.2% , 779 (Abortion without dilation and curettage), 21.1%, 725 (Benign prostatic hypertrophy with MCC), 19.3%, 686 (Kidney and urinary tract neoplasms with MCC), 18.7%
- added 12 items to the measures set for the reporting hospital quality data for annual payment update (RHQDAPU) program, and retired one current measure, mortality for selected surgical procedures (composite).
Reminder: Comments to CMS on 2011 IPPS proposed rule due June 18
Dear ACDIS members,
I want to remind you that comments to CMS on the FY 2011 IPPS proposed rule are due in by Friday, June 18, no later than 5 p.m. ET. The ACDIS advisory board plans to issue three comments to CMS on the following subjects:
- Proposed FY 2011 MS–DRG Documentation and Coding Adjustment (p. 23872)
- Proposed Change to the Severity Level for Acute Renal Failure, Unspecified Diagnosis Code (p. 23907)
- Changes to the ICD–9–CM Coding System, Including Discussion of the Replacement of the ICD–9–CM System With the ICD–10–CM and ICD–10–PCS Systems in FY 2014; Code Freeze (p. 23912)
Commenting on the rule is easy and may be done electronically at the Regulations.gov website. Click here to submit a comment http://www.regulations.gov/search/Regs/home.html#submitComment?R=0900006480ae60ba. The ACDIS advisory board encourages all members to comment and CMS welcomes comments from individuals as well as associations and groups.
You can read the FY 2011 IPPS proposed rule here: http://edocket.access.gpo.gov/2010/pdf/2010-9163.pdf.
Thanks,
Brian Murphy
Director, Association of Clinical Documentation Improvement Specialists
IPPS Proposed Rule includes 2.9% documentation and coding adjustment
Hospital reimbursement may experience an emergency if the 2011 IPPS Proposed Rule remains unchanged.
CMS published its 2011 Inpatient Prospective Payment System (IPPS) Proposed Rule Monday, April 19, making good on its 2010 threat to include a documentation and coding adjustment (DCA). The proposed DCA of 2.9% would bring the expected total hospital reimbursement down by 0.1%—or $142 million—for total payments of operating expenses.
The 2010 IPPS proposed rule included a 1.9% DCA. At the time experts called it the highest adjustment since CMS first introduced MS-DRGs in 2007. “It’s as though CMS is penalizing hospitals for documentation and coding improvement,” James Kennedy, MD, CCS, director of FTI Healthcare in Atlanta, said in a CDI Journal article at the time.
“They held off applying [the DCA adjustment] last year, but they’re proposing to recoup some of the additional payments due to case mix increases by making a 2.9% reduction in payments this year, even though we only got a 2.4% market basket increase, resulting in an overall reduction,” Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc., in Marblehead, MA, told JustCoding.com in a special report released Tuesday.
“This resulted in the standardized amount actually going down for the first time in recent memory,” Hoy said.
“I was surprised by the size of the [2011] documentation and coding adjustment,” Kennedy said in the special report, citing that the Medicare Payment Advisory Commission (Medpac) had recommended up to a 2% reduction in their report published in March 2010.
“CMS wishes to recover monies they believe that they overspent as a result of improved physician documentation and compliant coding practices,” Kennedy explains. The DCA represents just one more reason to implement CDI programs. The greater the specificity of physician documentation the greater the opportunity for complete and accurate payments as well.
Other CDI related changes include:
- Changes to HACs
- Expansion of quality measures
- MS-DRG revisions
CDI Strategies subscribers and ACDIS members received the complete 2011 IPPS Proposed Rule special report yesterday. Look for additional information in the Thursday, April 29, edition of CDI Strategies.
CMS abandons IPPS payment reduction for now
Though many hospitals feared a 1.9% reduction in payment for 2010, they will actually see a 2.1% increase, according to the fiscal year (FY) 2010 IPPS final rule that CMS released July 31. CMS had originally proposed a documentation and coding adjustment to account for the effect of increases in aggregate payments due to changes in hospital coding practices that it says do not reflect increases in patients’ severity of illness.
The proposed adjustment would have resulted in historically low payments for hospitals and especially penalize hospitals that have yet to develop a clinical documentation improvement (CDI) program, says DeAnne Bloomquist, RHIT, CCS, president and chief consultant for Mid-Continent Coding, Inc. in Overland Park, KS. “I think that means that hospitals can breathe a sigh of relief.”
In the proposed IPPS rule, CMS intended to reduce future payment rates “based on the observed increase in spending due to documentation and coding that occurred in fiscal 2008,” according to CMS’ press release. However, because it does not have a full year of data that would show the extent of documentation and coding effects on 2009, CMS decided not to implement the adjustment until it has a full year of FY 2009 data.
In the next year, hospitals with CDI programs should continue their initiatives, while those who have not implemented one yet should work toward that goal, says Gloryanne Bryant, RHIA, CCS, CCDS, Regional Managing HIM Director at Kaiser Foundation Health Plan Inc & Hospitals.
CDI implications included in IPPS proposed rule
The long-awaited fiscal year (FY) 2010 Inpatient Prospective Payment System (IPPS) proposed rule is out, and with it comes good and bad news for hospitals. Hospitals will see historically low payment updates with a phased-in documentation and coding adjustment (DCA) to take place over time.
The proposed update for acute care hospitals means an update of 2.1% for inflation minus a DCA of 1.9 percentage points. Long-term care hospitals will see a proposed update of 2.4% for inflation minus a DCA of 1.8 percentage points. These DCA adjustments reflect the differences between the changes in documentation and coding that do not reflect real changes in case-mix for discharges occurring during FY 2008, according to CMS.
These low rates won’t help hospitals struggling to keep their doors open in the midst of a worsening economy. “Hospitals that are counting on some sort of increase won’t really see anything this year,” says Kimberly Hoy, JD, CPC, director of Medicare compliance for HCPro, Inc. in Marblehead, MA. “Payments are going to stay flat, and that’s going to be tough for a lot of hospitals.”
Clinical documentation improvement programs as well as more diligent efforts by HIM are most likely the reasons behind more accurate coding that led to higher payments, agrees Shannon McCall, RHIA, CCS, CCS-P, CPC-I, director of HIM and coding for HCPro, Inc. in Marblehead, MA.
“CMS may have underestimated that facilities would create such effective clinical documentation improvement programs,” she says. “I think those programs were an integral part of all of this.”
And in light of decreased payment updates, hospitals that don’t currently have a clinical documentation program will need to think seriously about implementing one, says Gloryanne Bryant, RHIA, CCS, CHW senior director of corporate coding and HIM compliance in San Francisco.
“Hospitals will need to assess their current efforts to capture patient severity and acuity through documentation and coding to see if opportunities remain,” she says.
